Provider Demographics
NPI:1609161694
Name:HOUSMAN, ANNA (PAC)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:HOUSMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:PERDOMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 WATERCHASE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2110
Mailing Address - Country:US
Mailing Address - Phone:860-257-4131
Mailing Address - Fax:
Practice Address - Street 1:25 NEWELL RD STE E36
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5132
Practice Address - Country:US
Practice Address - Phone:860-583-9252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP0024980363AM0700X
CT002903363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008047053Medicaid